DailyKaizen

Over the last couple of years of writing on this blog I have probably written three of four posts discussing the need for the organization to cut down on the amount of improvement work in progess and to focus on only those improvements that will be truly transformational for the patients we serve.  So what the heck, why not a fifth?  I am worried that this year we may repeat the mistakes of the past so I wanted to write this post to share some of my thinking.

So why is there a lack of focus?  Overall, we really are an amazing organization at coming up with innovative ideas and solutions.  Since we lack an organizational competency in developing improvement hypothesis based on data (although we are getting better) most ideas end up being good ideas.  Additioanlly, because it is a lot easier to say yes then it is to say no we end up with far more work in the pipeline then we can get done.  As a result, the same leaders get tagged with leading far to many improvements.  The same supporting resources have far to many number one priorities.  The work drags on slowly and we don’t achieve the results we all know we are possible of achieving.  I am sure that many of you readers know this story pretty well since I am sure we are not alone in having this problem. 

The good news is that over the last couple of years there have been a couple of times that the organization has taken a piece of work and really focused.  When this has happened the results have always been impressive.  Implementing our electronic medical record, rolling out the Model Line in our Health Plan, developing our five year strategic plan and developing our enterprise value stream maps are all examples.  In each of these cases there has been a razor focus of leadership and supporting resources on getting high quality work done very quickly.  In a relatively short period of time work moved forward rapidly and people lined up to support the work.  Why was this work successful?  It is because the entire organization focused on moving this work forward.  From the senior leaders to the front line staff.  The problem is that when we have been successful it has taken a huge amount of organizational energy to make it happen.   

The organization needs to look at these improvements as examples of what is possible when we focus.  What if we were able to put this amount of focus and energy into each of our strategies?  The results would be far better then the norm.  Yet, this will only be possible if we limit the work in the system.  Focus on three or four things at a time as oppossed to fifteen or twenty and get them done thoroughly and quickly.  An interesting challenge we will continue to wrestle with.

Its been a long time since I woke up on a Saturday morning and had the energy to walk down my hallway and log onto my computer.  The last couple of months have been exhausting and to be honest I have felt removed from the work.  For the last year I have worked hard with our leadership team to define and implement a strategy deployment system.  While this work has been important it has meant I have been removed from the gemba for far too much of my time.  As the cloudy days of rain have come marching into Seattle I have gotten into somewhat of a “work funk” and its stuck with me for the last couple of months until yesterday, when finally, with a little help from a great team I broke out of it. 

For those of you that are not as familiar with healthcare there is currently a crisis happening in this country with Primary care based medicine.  Poorly designed incentives, long work hours, an over emphasis on throughput and a lack of financial reward have resulted in huge shortages of Primary Care physicians.  Many have burned out and students entering Medical School are choosing to become specialists as opposed to generalists.  This has put a huge strain on the the healthcare system with less preventative medicine, more expensive services, etc.  Being a Primary Care based system our leadership a couple of years ago decided that they were going to do something about this challenge.  They defined a set of principles that are patient centered, identified a pilot clinic and empowered a team of clinicians to help us define a new model of care that would be transformational.  Not just transformational for our clinicians, but also transformational for our patients.  This team has answered this charge and have created a new model for care that has resulted in improvement across almost every standard.  Now the challenge of the organization is to take this model of care and deploy it across all 26 of our medical centers.  Lean has provided the means by which the organization can make this happen. 

I have mentioned before in the last couple of posts that I would be transitioning my work at my own request and spending more and more of my time partnering with the leaders of our clinical teams.  Late Friday afternoon I drove out to hear a report out from a RPIW (rapid process improvement workshop) that had taken place all week in this pilot clinic.   The focus of the event was standardizing the process by which clinicians practice virtual medicine.  Allowing patients to get care in a convenient and timely way, clinicians to manage the chronically ill far more effectively and all around leveraging out model of care.  It truly would make a great case study in James Womack’s book Lean Solutions. 

As I sat in the back row and listed to the team of nurses, staff and physicians report out on the results of the five day event I could not help but think I was whitnessing an event with a far greater purpose then improving the systems of Group Health.  I have been to dozens of these type of report-outs in the past and as most of you know they are always exciting.  For me, this one was different.  There was a level of excitement in the room that I think can only be created when a team has figured out that they are onto something.  That something is a new system of providing medicine that connects back to the ideals that made them become caretakers in the first place.  An ideal that was lost somewhere along the way and was again awaken. 

Physicians stepped up and told story after story about how much more effective they are in taking care of their patients   They talked about how they intended to retire and now there was no way they were leaving.  They asked little of the senior leaders in the room, just thanked them for allowing them to have the opportunity to participate and urged them to continue to push this work forward.  The team was vested in the success of far more then the event itself.  They pledged to help spread the word to other parts of the organization and champion the change.  It was the definition of engagement in practice. 

While this might sound cheesy as I listened to the team tell their stories I could feel myself waking up.  My mind started to search for ways that I could join in and help move this system forward.  How I can help make this team successful.  Since walking out of the room I have been filled with energy.  Enough energy to get me up out of bed and in front of the computer on a Saturday morning.

Lee commented to me that I hadn’t posted in awhile (a long while) so I thought I would jump in to let readers know that our paths are forking in a more sustained way.

I have accepted a position with The Permanente Federation, LLC, and have made Washington, DC my permanent home, leaving Seattle (”The other Washington”), and am still on the LEAN journey, now starting at a different level. This company supports the 8 medical groups of Kaiser Permanente and Group Health Permanente, the medical group associated with Group Health Cooperative, where Lee works. We’re still technically in the same family, luckily.

I’m a little bit of a Desi Porter (for those of you who have picked up John Shook’s latest book from the Lean Enterprise Institute), given a charge and pursuing the same steps that Desi is in the book, to create a strategy for improvement in a specific area. The improvement methodologies in this organization are dynamic and changing, which is an opportunity for me to start at the beginning, with a Gemba Tour, hosted by one of Kaisier Permanente’s regions. That’s where I am now in real life. I’m farther ahead in the reading in John Shook’s book - I work at a different level in this organization, so it is much more important to take the time to go through the steps of managing to learn. Publication of the book was great timing in that regard.

I’m being given license to blog about my experiences, as was the case at Group Health Cooperative. I will blog mostly about them on my professional blog at http://www.tedeytan.com, which integrates my interests in patient empowerment, the Washington, DC region, and LEAN, all together. There’s an RSS feed that can be subscribed to there, of course. I think all three things fit really well together, and in 2008 in this part of the country, especially so!

It’s worth pointing out that this blog has been going since 2005, establishing the value (I think) of health care organizations talking about their journeys publicly. Who’s next?

I spent some time this morning working through some strategic improvement plans that our senior leadership team is developing.  I asked myself how do we know if this is the right work several times.  The answer was always the same, we don’t know.  While we know more now about the organization then we ever have we still don’t know enough so we are often having to make decisions based on intuition.  Our current measurement systems are not capable of helping us really understand our performance.  They are built to support the individual departments and divisions, but tell us very little about where we are and where we need to go.  With the exception of the areas where we have driven Lean thinking deeply from a strategic and from an operational perspective we don’t currently have sufficient measurement capabilities to really understand our business.

Having just finished our first enterprise value stream work this gap is really on my mind.  I understand very clearly that our current measurement systems are broken and drive the wrong and wasteful behavior and that a major focus of our value stream improvement work this year will be to begin to change these systems.  I can’t tell you how many times during this work we visited teams where measures were not used at all or if they were they were almost completely outcome focused.  In other words the measures were not integrated into the work nor were the used by the teams to focus improvement efforts.  In most cases the measures existed for one of two reasons: either we were measuring something for reporting to outside stakeholders or we were using measures to monitor individual performance (productivity) as opposed to process performance.  As you can imagine this led to all kinds of problems and sub-optimization. 

Even in areas where we have done a lot of Lean work we still have a long way to go.  Last week I was talking with a leader who is frustrated with the rate of improvement and struggling with why things are not moving faster.  When I reviewed their improvement plans it was clear that the leader had not changed the metrics of the area.  This leaders team was getting mixed messages.  The leader was asking them to work differently as a team, but measuring them as individuals.   The leader may say things are going to be different, but without changing the measures it is unlikely that people behaviors are going to change.  I pointed this disconnection out to the leader and they quickly realized that this was a problem.  The good news is that later in the week I got an email from the leader who had already begun to work with her team to change the measures. 

This last example I shared is exactly how we will put the measurement system in place that we need.  One team and one process at a time.  We need to change the thinking and then change the measures.  It will be hard work, but its the right work.

For the last year my focus and the focus of much of our Lean efforts in the organization has been in putting in place an effective Strategy Deployment system.  This included completely changing the way we develop and deploy goals and strategies as well as putting in the foundational processes and systems to support checking and adjusting.  It has been a very successful year thus far and we have a very engage leadership team and the foundations of a management system that we can continue to build out over the years to come. 

From a personal perspective I have learned a lot this year, but over the last couple of months I have grown inpatient.  For people that know me I am a person that thrives on the tension that is created by learning new things by doing them, especially when there is a lot of pressure to get things done quickly.  I get bored quickly with doing things I have done before and as a result often go out and find ways to get myself into new types of work that will require big organizational change and the associated learnings that will come with this change.  One of the Sensei I work with called it last week “creating opportunistic trouble.”   

So back to my inpatience.  As the Strategic Deployment system has become more stable, which is a good thing, I have grown a little frustrated with the process.  Not to say that there are not plenty of opportunities to improve the process.  Its just no longer has the edginess it once had when we were first putting it in place.  So the good news is that there are plenty of opportuntities to take on new, and challenging work.  Over the next year we will be focusing on putting in place the cross-functional and daily management systems across the organization.  We have early experience in both systems, but they are not widely integrated into our management system.  Figuring out how to put these systems in place will cause all kinds of “organizational trouble” and it seems like the natural place for me to focus.  This work will allow me to spend more time in the gemba, to learn new skills/thinking and to hopefully bring new and more interesting content to this blog.  So stay tuned…

We are now at a place as an organization where we are struggling with how we can effectively “scale” our Lean work across an enterprise of over 10,000 employees with locations across two states.  As you can imagine there are all kinds of people and process challenges.  One of the most interesting is how do we manage the effective “spread” of standard work across individuals, teams and locations.  We have thirty specialty service lines, twenty-six clinics, ancillaries, dozens of administrative teams, etc. all either already standardizing their processes or about to start.  Many of these teams are focused on delivering to the same set of customer requirements, but do not currently have the same baseline that they are staring from.  For example, everyone of our clinics has a different work environment (some very big and some very small), different staffing ratios and different processes.  Its hard enough deploying standard work in one location, but daunting to think about trying to spread it across twenty-six!

Over the last six months my thinking has greatly evolved.  I now believe that it is less important for every one of our work teams to have shared standard work for all their processes.  To try and drive that level of consistency across work teams would not only take an incredible amount of resources, but also create an enviornment that would be ridgid, slow to improve and take creativity away from the people doing the work.  Instead, every team needs to be focused and held accountable to developing their own standard work that everyone follows within the team that reliabily meets the standard each and every time the work is completed.  In other words, all teams must meet the standard, but they don’t all have to have the same processes in place to meet that standard.  There may still be certain processes that in order to meet customer requirements need to be performed consistently across teams, but most processes are invisible to customers and will not meet this requirement.

By taking this approach the organization can focus its time in more effective ways.  Rather then spending a huge amount of resources and time trying to maintain standard work across teams the organization can instead focus on developing systems that make performance transparent and developing incentive systems that encourage teams to share their work.  If done right, low performing teams for any process should be incentivized to learn from high performing teams and possibly adopt their standard work.  Conversely, high performing teams should always be looking to find low performing teams that they can lend a helping hand in support.

I am wondering if others have thoughts on this approach?

This last week we began the second cycle of our strategy deployment process with a catchball event that brought together the top 100 or so leaders of the organization.  During the event the broad goals for the year were shared by the executive teams and our major Operating Divisions began vetting the potential list of strategies for 2009.  This process will continue for the next four weeks as more and more parts of the organization are brought into the process and the sufficient means are identified to achieve our yearly goals.   During this time the organization needs to decide what current improvement work will continue and what new improvement work will begin.

As I walked around the room it was exciting to see how engaged everyone was in the process.  Its fun work to vet and define improvement work.  And boy as an organization we sure are good at it.  This is evident by the dozens of improvement strategies that are currently in process and the dozens more that are waiting in inventory.   And yes, this is a problem.  A problem that we all know about, but have not been very effective in solving.  We are really good at saying yes and really bad at saying no and equally as bad at stopping work that no longer should continue.  This leads us to each year take on far more improvement work then we can complete with available resources.  This causes all kinds of inefficiencies that are no different then allowing a production process to develop inventory and backlog.  Long cycle times and low throughput means that improvements end up being outdated, slow to mature and often lose much of their potential for results as time slips by. 

So how does this happen?  There are many causes all of which we can solve over time (many we are working on right now).  Looking at the history of the organization causes include:

• A lack of sufficient data and information meaning that all improvements are good improvements
• A lack of a Value Stream view meaning that each silo is focused on improving itself, but loses the large potential improvements that come from improving across our system
• A lack of understanding of capacity and how much discretionary resource is available.  This leads to over and under commitment of resources
• A lack of a strategic planning and deployment system that makes work transparent and drives organizational focus
• A lack of stable and standardized processes that means leaders who should be working on improvement work are often called to stop what they are doing and focus on firefighting
• etc.

The good news is that we are making improvements on all of the causes listed above.  While our new strategic deployment process did not help us stop a lot of working during its first cycle it did help us for the first time make all the work visible.  This is a huge improvement and should allow us to get a little better this year at focusing our resources.  Additionally, we have Value Stream work underway, we are engaging far more people in the planning process, more and more processes are being standardized, etc. 

Over time we will become more focused, but there is no silver bullet.  Just a lot of really hard work at breaking down barriers, connecting and putting in new management systems and learning more and more about the organization.  In the interim the heavy lifting will fall to our senior leaders in making tough choices with incomplete information.  We all will need to help them in making it okay to say no and okay to stop work.  I remember reading an article a while back that said something to the effect of ‘leadership is more about knowing what not to do then it is about telling people what to do.’  I could not agree more.

Sorry to all the readers of this blog that I have not written very much lately.  The last month has been really busy and I have not had much opportunity to step away and reflect on everything that is happening.  We are in the process of defining our enterprise Value Streams, starting the second cycle of our strategy deployment process, redefining our budgeting process, etc.  The pace of change seems to grow daily. Walking out the door this Friday evening I was chatting with my Sensei and we were both really tired, yet, full of optimism.  She looked over at me and asked “did you every think we would get the company to go this far?”  Honestly, I am a pretty optimistic person, but I would be lying if I said yes. 

Our biggest challenge now as a Lean group is helping senior leadership bring it all together.  This marks a real and substantial change in our focus.  For the last couple of years as a team we have been working opportunistically to identify leaders that could become Lean champions and to support them in driving business results.  In many ways a “proof of concept” effort.  In the last seven to eight months this has changed as senior leaders have embraced Lean as a business strategy and management system.  The conversations are far more exciting and often challenging now then they were in the past.  Its no longer about “if” we do this, it now about “how” we do it.

A year ago a senior leader in the organization described our organization as collection of “900 management systems”, one for every manager in the organization.  So when I say we need to bring it all together what do I mean?  Basically, starting last year with our strategy deployment work we began to define and standardize the management system of the organization.  It was just a first step, but it gave us a foundation that we can now begin to systematically build out from defining management practices one at a time and ensuring that the entire system works effectively together.  There are countless examples of management practices that we need to standardize and bring into alignment.  Many of which we are already working on.  This includes our budgeting process, compensation, job design, measurement, etc.  The best current example is our work over the last month with Value Streams.  Value Streams as a management system and not just and improvement tool. 

We are simply taking the same thinking and practices we use to improve our work processes by implementing standard work and PDCA and applying them to our management practices.  We believe that by creating a single system that can be describes as the “way we” manage at Group Health we will create a strategic advantage that drives business performance.   This will not be easy, but a year ago I would have never believed we would even be starting this work.  Progress!

Healthcare is a heavily regulated industry.  There are literally dozens of government agencies and oversight organizations that have an oversight function.  This means there are lots of rules, regulations and policies that have an impact on almost every process.  While often all of this oversight can be frustrating and wasteful for the most part it serves a purpose.  Regardless, it is only good business to make sure that you are compliant.

Over the last couple of weeks during the value stream work it has been interesting to see how rules and regulations have been interpreted and deployed into the processes of the organization.  As we conduct process walks I have learned that you need to question every rule.  So often we have heard teams tell us that things cannot be changed or improved, because of a rule or a policy.  While much of the time this is very much the case, just as often it proves to be more perception or interpretation then fact.  For example, we visited a team early last week that had a double check built into their process that greatly increased cycle times.  The team believed that this check was necessary as defined by a government agency, but this was not really the case.  At one point, years ago, this checking process was required, but the regulations had changed.  This change had never been communicated, so the team continued to over-produce. 

Let me be clear that my message is not to encourage teams to not be complient.  I am simply calling out that so often what we believe to be true, or what once was true in no-longer true.  In highly regulated industries it is very important for organizations to not be passive about understanding, managing and communicating rules and regulations.  These rules will constantly be changing and teams doing the work need to be supported in helping interpret or deploy these changes.

Four years ago when I first began working in healthcare I was amazed how difficult it was to get work done outside of a functional area.  I worked at three different organizations during graduate school (internships) and then took a job with my current employer and all of them were completely siloed.  The first internship I worked with a team that had such a bad relationship with the teams up and down stream that they basically refused to even talk to their co-workers unless a problem got so bad it could not be ignored.  At a different organization I worked with a team where 50% of their work was sorting documents in a certain way so that they could be scanned by another team.  The team downstream changed their software and suddenly they did not need to have the documents sorted in the old way.  For some reason the message never got to the upstream team for almost three years, meaning that two full FTE’s worth of work was wasted for the entire time.  I could only shake my head. 

For some reason healthcare organizations really struggle with cross-functional management and improvement.  I am not sure the root cause for this challenge but I can guess it has to do with the following:

• A lack of clarity of who the customer is
• A lack of translation of customer requirements into work processes
• Lack of effective measurement systems
• Functional as opposed to cross-functional goals
• Budget > Strategy
• Specialization of work roles that set up long-standing hierarchy
• Antiquated structures and excess bureaucracy
• etc.

As you all know silos drive incredible amounts of waste and lead to all kinds of performance related issues.  As we began the Value Stream work this week that I discussed in my last post the team I am working with was quite literally blown away by the potential we found for improvement event though we just started.  Every team we visited was doing redundant work, over processing, missing opportunities to better serve their customers, had work processes that led to problems downstream, etc.  All of this because the teams were not connected to the teams either up or down stream from them. 

 The healthcare organizations that figure out how to overcome this issue will dominate over their competition.  One of the things that most excites me about Lean is that it provides a solution to this challenge.  There is evidence all over my organization that silos are in the early stages of breaking down.  The Value stream work is just one of many examples of how we are learning how to better understand our customers and then align our process across to better serve them.  Very exciting.